Childbirth - pain relief options

There are many options available for pain relief during childbirth in Australia. Some women choose self-care measures to relieve labour pain, while others prefer medicines. It helps to know what choices are available before you are due to give birth, and the advantages and disadvantages of each option. Pain relief may also be needed after you have your baby, especially if you have had a complicated birth or Caesarean section.

Antenatal classes are a good way for you (and your partner or birth support person) to find out more about labour, childbirth, and available pain-relief options. Discuss pain relief with your doctor and/or midwife during your pregnancy. You may want to record your pain relief preferences in a birth plan, but remember that it’s okay to alter the plan with the guidance of your midwife or doctor during labour if you need to, or if things are not going exactly to plan.

What causes pain during labour and childbirth?

Pain during labour and vaginal delivery is due to:

contractions of the uterus;

stretching of the cervix as it dilates; and

stretching of the vagina and perineum (area between the vagina and anus) as the baby is being born.

Labour pain is often described as being similar to period pain, but it is more severe and comes and goes. Backache is also common during labour. During a vaginal delivery, you may feel stretching and burning in your vagina.

Self-care measures for labour pain

There are several self-care measures that you can try during labour to both relieve pain and reduce any stress and anxiety, which can make pain seem worse. These include:

breathing techniques to help you relax and give you something to focus on;

massage;

having a warm bath or shower;

hot or cold packs; and

moving about regularly, including walking around, rocking your pelvis back and forth and changing positions (sometimes called active labour).

Some women may want to try complementary therapies for pain relief during labour, including hypnosis, acupuncture or aromatherapy. Most complementary therapies have not been proven to relieve childbirth pain. You should check with your healthcare providers about the use of these therapies and their availability at the centre where you plan to give birth.

TENS - transcutaneous electrical nerve stimulation

Using a device called a TENS machine can help relieve the back pain that many women experience in early labour. TENS - transcutaneous electrical nerve stimulation - involves using a small, portable machine that transmits gentle electrical pulses via electrodes attached to the skin on your back.

TENS is thought to work by increasing the release of endorphins (natural painkilling substances that are made in response to pain and stress) and reducing pain signals to the brain via the spinal cord. TENS is safe for most people and has few side effects, but some women don’t like the sensation of TENS.

Sterile water injections

Sterile water injections have been used in some centres in Australia to help relieve back pain during labour. This procedure involves injecting small amounts of sterile water into the skin (or just under the skin) of the back - usually in 4 areas of the lower back. The injections sting at first, but after the initial stinging sensation they may help relieve back pain.

While more evidence from clinical trials is needed to show that sterile water injections are effective for back pain relief in labour, they appear to be safe for mother and baby.

Nitrous oxide gas (gas and air)

Nitrous oxide gas (also known as laughing gas) and oxygen can be given during labour to help with the pain of contractions. The nitrous oxide plus oxygen (sometimes called gas and air) doesn’t usually completely relieve the pain of labour, but makes it more manageable.

The gas is breathed in through a mouthpiece or mask, and is most effective when breathed in about 30 seconds before a contraction is expected and stopping as the contraction eases. Slow, deep breaths work best. Many women like this pain-relief option because they feel in control - they can breathe the gas when they are ready and stop at any time.

Some women feel dizzy, light-headed, woozy or nauseous (sick) when using nitrous oxide gas, but side effects can often be minimised by adjusting the concentration of the gas. There are no known harmful effects on the mother or baby.

Pethidine/morphine injection

Strong pain relievers such as pethidine or morphine can be injected (usually into the muscles of the thigh or buttocks) for pain relief during labour. These opioid medicines can help control pain, but usually they do not completely relieve pain.

The most common risks for the mother are side effects such as nausea and drowsiness. Other possible side effects for the mother include difficulty passing urine, hallucinations, breathing difficulties and allergic reaction.

Pethidine/morphine should not be given too close to the birth (less than 2 hours beforehand) as they can cause breathing problems in the baby. They can also make the baby sleepy, which can affect breast feeding just after the birth.

Epidural

An epidural is a type of regional anaesthetic - that’s one which affects only a specific area of the body, not the whole body. Epidurals can often give complete pain relief during labour by temporarily blocking the nerves that carry pain signals from the uterus (womb) and cervix to the brain. When you have an epidural you are still conscious. It’s also often possible to still feel that contractions are occurring (although they are no longer painful), and to feel the urge to push when it is time.

If you are giving birth in a hospital maternity unit, you can usually request to have an epidural. Be aware that it does take up to about half an hour for an epidural to be given and take effect. While you can have an epidural at any stage during labour, they are usually not performed once the baby has entered the birth canal (stage 2 of labour) because the baby is usually born very soon afterwards.

Epidurals are not available in birth centres, and some women with certain medical conditions or taking certain medicines cannot have an epidural - check with your doctor or midwife.

How an epidural is given

Having an epidural involves an anaesthetist injecting local anaesthetic medicine (and sometimes also opioid painkilling medicines) into the epidural space in your spine. (The epidural space is just outside the membrane that surrounds the spinal cord, called the dura mater.)

The anaesthetist will ask you to sit hunched forward over a pillow or curled on your side. This is to allow the spaces between the bones of your spine to open up as much as possible so that the anaesthetist can find the epidural space more easily. It is vital not to move throughout the procedure.

After cleaning the skin with antiseptic, the anaesthetist will inject some local anaesthetic into the skin (which may cause a slight stinging or burning sensation) before inserting an epidural needle into the gap between two of your vertebrae (bones) of the lower spine to reach the epidural space. When the epidural needle is inserted you may feel a pushing sensation, but it will not hurt.

A catheter (thin tube) is then inserted through the needle before the needle is taken out. The catheter, which is taped to the skin, then allows the anaesthetist to deliver the anaesthetic and top it up, if required.

A skilled anaesthetist can control the amount of pain relief or numbness you receive, while still allowing you to retain some sensation and some movement. This is because the nerve fibres that transmit pain are relatively thin, and are affected by the anaesthetic more quickly compared with the nerve fibres that allow movement of the muscles or the sensation of touch. In addition, the anaesthetist can adjust the strength of the anaesthetic to offer a fine balance between pain relief and the ability to move.

Risks of an epidural

Having an epidural (or epidural block) means that you'll need to have a drip inserted in your arm to give fluids or medicines if necessary. A catheter may be inserted to drain your bladder. Your contractions and your baby’s heart rate will also need to be monitored. Because an epidural can affect the nerves to your legs, they can feel weak, numb and heavy. You can usually still move, but will most likely not be able to walk during labour.

Epidurals can cause your blood pressure to drop, so you will need to have regular blood pressure monitoring. A drop in blood pressure can make you feel sick or light-headed. Because an epidural can affect your body's temperature control system, some women feel cold and shiver. You may also feel itchy if opioids were used.

An epidural can slow down the second stage of labour, and in some cases the epidural may numb you so much that you can’t feel your contractions and don't have enough muscle control to push your baby out. This means that there is an increased risk of having an assisted delivery (for example with forceps or vacuum-assisted delivery). However, the risk of needing an emergency Caesarean is not increased by having an epidural.

It is also possible, though rare, that the epidural needle may accidentally puncture the membrane that surrounds the spinal cord (the dura mater), resulting in a painful ‘spinal headache’ afterwards. These headaches are worse when you stand up, so if this happens you usually need to remain lying down for a day or 2.

Epidural and spinal blocks for Caesarean delivery

Regional anaesthetic (anaesthetic that affects a specific region of the body) is usually used for a Caesarean delivery. It means you can be awake and alert during the birth of your baby without feeling any pain. An epidural block, spinal block, or a combined spinal-epidural block is usually used.

A spinal block is slightly different to an epidural. It involves giving a single, smaller dose of local anaesthetic medicine. The medicine is injected with a small needle into the cerebrospinal fluid (CSF) that surrounds the spinal cord.

Following surgery, most women cannot feel or move their legs for several hours, and will need to stay in bed for about 24 hours. If you have an epidural, it can remain in place to deliver painkilling drugs such as morphine or pethidine after the surgery, although different hospitals may have different policies about offering this as an option. The epidural is usually removed after a day or so, and oral medicines (medicines taken by mouth) are usually given to control any pain.

Bear in mind that if an emergency Caesarean section is needed it may sometimes not be possible to have an epidural or spinal block, and a general anaesthetic will be used. This means you will be unconscious.

Support during labour

Remember, talking to your healthcare team about pain relief well before you are due to give birth can help you feel more in control when you do go into labour. You may want to change any pain relief plans you have as labour progresses - try to keep an open mind, especially if this is your first baby.

Most women find it helpful and comforting to have their partner or another support person present at the birth. Your support person can find out how best to help you during labour by attending antenatal classes and/or prenatal appointments. In addition to medical care, your midwife and doctor will also provide support during the birth of your baby.

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